1. Pyelonephritis

2. Pathophysiology and aetiology
Definition
It is Bacterial infection of the renal pelvis, tubules and interstitial tissue of one or both kidneys
potentially organ- and/or life-threatening infection that characteristically causes some scarring of the kidney with each infection and may lead to significant damage to the kidney
Pathophysiology and aetiology
Infection usually ascends from the urethra most bacterial causes bowel organisms eg Ecoli (70-80%)
Hospital-acquired infections may be due to coliforms and enterococci.
Haematogenous spread is rare eg Staph aureus
Frequently due to ureterovesical reflux

3. Complicated UTI Etiology
(%)
Escherichia coli
Klebsiella pneumoniae
Enterobacter species
Citrobacter species
Proteus mirabilis
Providencia species
Pseudomonas aeruginosa
Enterococci species
21 – 54
1.9 – 17
1.9 – 9.6
4.7 – 6.1
0.9 – 9.6 18
2 – 19
6.1 – 23

4. Interstitial infiltration of inflammatory cells
Pyelonephritis may be acute or chronic
Pathology
Kidneys enlarge
Interstitial infiltration of inflammatory cells
Abscesses on the capsule and at corticomedullary junction
Result in destruction of tubules and the glomeruli
When chronic, kidneys become scarred, contracted and nonfunctioning

5. Pathogenesis
• Rectal and/or vaginal reservoirs • Colonization of perianal area • Bacterial migration to perivaginal area • Bacteria ascend through urethra to bladder • Intercourse may contribute urethral colonization and ascending infection • ASB in 1st trimester of pregnancy may cause pyelonephritis in 3rd trimester

6. Renal angle tenderness Confusion in elderly Leukocytosis Pyuria
Clinical Manifestations of acute pyelonephritis
Symptoms develop rapidly (<24 hours) and may include:
Acutely ill
Chills
Fever >38°C
Flank pain and
Nausea/vomiting
Renal angle tenderness
Confusion in elderly
Leukocytosis
Pyuria
Bacteriuria
In addition symptoms of lower tract involvement
Dysuria
Frequency

7. Risk factors Mechanical: Constitutional:
Structural abnormalities to the kidneys and the urinary tract
vesicoureteral reflux (VUR) especially in young children,
calculi
urinary tract catheterisation
nephrostomy
pregnancy
neurogenic bladder (e.g. due to spinal cord damage, spina bifida or multiple sclerosis) and
prostate disease (e.g. benign prostatic hyperplasia) in men
bladder tumours
urethral strictures
Constitutional:
diabetes mellitus, immunocompromised states

8. Diagnosis Is not always straightforward
A number of studies using immunochemical markers have shown that many women, who initially present with lower tract symptoms, actually have pyelonephritis
The extremes of age, the presentation may be so atypical (feeding difficulty or fever)
In the elderly presentation may be mental status change or fever

9. Laboratory Diagnosis of pyelonephritis
Urinalysis
10 WBC/hpf is the usual upper limit of normal
Positive result on leukocyte esterase dipstick
test correlates well for detecting >10 WBC/hpf,
with a specificity of 65%–95%, and sensitivity
of 75%–95%
Positive nitrate reduction test dipstick test result for
bacteriuria is only moderately reliable;
false-negative results are common
Urine culture and sensitivity
Blood culture

10. Radiological investigations
CT scan
IVP=intra venous pyelogram
Radionucleotide imaging with gallium citrate and indium-111-labeled WBCs

11. Micturiting cystourethrogram (MCW showing bilateral VUR, grade IV on right and grade III on left-side. There is bilateral ureteral and pelvic dilation with blunting of fornices in the right kidney.

12. Bilateral reflux extending into the pelvicalyceal systems of the kidney without dilatation of the calyces or ureters. (Note catheter in bladder)

13. Medical Management
Treated as outpatients if there is no nausea, vomiting or dehydration and other signs and symptoms of sepsis
Very ill patients and all pregnant women are hospitalized at least for 2 to 3 days for parenteral therapy
2 weeks course
Bactrim [trimethoprim /sulpha
Ciprofloxacin
Gentamicin with or without amoxicillin

14. Problem
Chronic or recurring symptomless infection persisting for months or years
Another 6 weeks course if relapse
Follow up urine culture 2 weeks after completion of therapy

15. Chronic Pyelonephritis
Repeated bouts of acute pyelonephritis may lead to chronic pyelonephritis
Clinical manifestations
No symptoms of infection unless an acute exacerbation occurs
Fatigue
Head ache
Poor appetite
Polyuria
Excessive thirst
Weight loss
Progressive scarring  renal failure

16. Culture and sensitivity ESRD=end stage renal disease Hypertension
Assessment and diagnostic findings
IVP
Serum creatinine
Blood urea
Culture and sensitivity
Complications
ESRD=end stage renal disease
Hypertension
Kidney stones
Medical management
According to C&S result
Drugs carefully titrated if renal function is impaired
ESRD = end stage renal disease

17. Fluid balance – I / O chart Fluids encouraged unless contraindicated
Nursing management
Fluid balance – I / O chart
Fluids encouraged unless contraindicated
4th hourly temp
Antibiotics
Bed rest
Teach how to prevent recurrent infections : adequate fluids, emptying the bladder regularly and performing recommended perineal hygiene taking antibiotics as prescribed

18. Treatment Guidelines: Acute Uncomplicated Pyelonephritis
Mild or moderate symptoms:
 Outpatient treatment (total of 7–14 days)
oral treatment:
 Fluoroquinolone
 TMP/SMX, if uropathogen is known to
be susceptible
 If Gram-positive pathogen: amoxicillin
or amoxicillin-clavulanate

19. Treatment of Pyelonephritis
Eradicate pathogens in kidney and urothelium, and treat/prevent bacteremia
 Hospitalized patients:
IV antibiotic first 48–72 hours followed by 7 days of oral antibiotic therapy
Fluoroquinolone IV, then PO
Aminoglycoside ± ampicillin IV, then TMP/SMX PO
Third-generation cephalosporin IV, then TMP/SMX PO
 Ambulatory patients: 7–14 days of PO therapy with one of the antimicrobials above

20. Scarred and contorted kidneys

21. Destruction of approximately 70% of the kidney
Destruction of approximately 70% of the kidney. Numerous dilated calyces with yellow-brown calculi. The central necrotic areas are surrounded by dense fibrosis.

22. Case 1
You are contacted by a resident regarding the use of a FQ[FLUORQUINOLONES]
in a 24 year old semi-professional soccer player with an
apparent UTI.
he has complained of dysuria and frequency for the last 24 hours. Her UA is positive for bacteria using a nitrate
dipstick and WBC’s using a dipstick esterase test.
Her past medical history is significant for DM. She has no
allergies other than her diabetes there has been no
other significant medical problems.

23. Case 2
An asymptomatic 84 year old male with an indwelling foley catheter has a positive urine culture for P. aeruginosa. You have been contacted regarding the appropriate dose and interval for ciprofloxacin to begin therapy.

24. Case 3
You have been consulted on a 72 year old female nursing home patient. She recently was treated for 10 days with ceftriaxone and azithromycin for presumed CAP. During her hospitalization a foley catheter was placed. She is currently afebrile and asymptomatic of any UTI symptoms but a culture of her urine at the end of her antibiotic therapy had a significant growth of yeast. How should she be managed?